Medical students say given the Dobbs v. Jackson Women’s Health Organization decision overturning Roe v. Wade, they must reckon with a landscape of rapidly changing abortion laws, where litigation often makes it difficult to determine what is legal where .
Usually, “doctors don’t go to medical school and go into medicine because we like to interact with the legal profession,” says Katie McHugh, an Indiana obstetrician-gynecologist and board member of Physicians for Reproductive Health.
The OB-GYN shortage comes at a critical time: In 2021, the Centers for Disease Control and Prevention documented gains in cesarean rates, preterm birth rates, and low birth weight, all of which can exacerbate other health risks and require specialized care.
As the first batch of post-Dobbs medical students prepares to be matched with OB-GYN residency programs on Friday, preliminary 2023 data from the American Association of Medical Colleges shows that the average number of applications per obstetrics and gynecology residency program dropped from 663 in 2022 to 650 in 2023.
A CQ Roll Call analysis found that 84 of 299, or 28%, obstetrics and gynecology residency programs accredited by the Accreditation Council for Graduate Medical Education are located in states or territories that enforce abortion bans.
Although no regional data on applicants are available, some students expressed in interviews a reluctance to receive training in states with an abortion ban that could affect their scope of medical education.
Isiah Romo, a fourth-year medical student at the University of Arizona College of Medicine who hopes to match this year in an obstetrics and gynecology program, said he had applied to a number of programs but was considering none in states where he couldn’t get abortion training.
He said while the fallout from last summer’s Dobbs decision may make the field less attractive to some people, it has solidified his interest. Still, he said, “it’s probably causing a lot of other people not to sign up, which just creates more gaps for the people who need the care.”
The US consistently scores poorly in maternal care and outcomes compared to other developed countries. OB-GYNs warn that if the deficiency is not addressed, the problem will only get worse.
More than 2.2 million women of childbearing age live in so-called maternity deserts with no hospitals providing obstetric care, obstetric care providers or birthing centers, according to the March of Dimes. An additional 4.7 million women of childbearing age live in counties with limited access to health care.
Many are in remote and rural parts of the country, with a particular concentration in the Midwest.
“Hospital closures, combined with the lack of access to outpatient and inpatient obstetric care, are resulting in the extreme maternal and infant mortality rates we see in my state,” McHugh said in Indiana.
Half of all U.S. counties don’t have a midwife, said Elizabeth Cherot, chief medical and health officer at March of Dimes.
In practice, this means that pregnant women are faced with the choice of traveling long distances for care or skipping an appointment.
Pregnant women who don’t receive prenatal care are three to four times more likely to experience pregnancy-related death, Cherot said.
Babies in deserts of concern are also more likely to be born prematurely or underweight, according to the March of Dimes.
Major legislators have highlighted health worker issues as something to focus on, but incentives like loan forgiveness or expanding the graduate medical education system are long-term strategies that require building specialized skills, and the need is now acute.
“It’s something that has actually worried me for years that it was on the horizon,” says Rep. Michael C. Burgess, R-Texas, a trained OB-GYN.
Burgess pointed to a 2018 maternity care bill as an example of what Congress can do to alleviate midwifery shortages.
The law prompted the Health Resources and Services Administration to identify areas within health worker shortage areas where there is a shortage of maternity care providers to allocate more midwives to these areas.
Senate Health, Education, Labor and Pensions Committee Chair Bernie Sanders, I-Vt., and Distinguished Member Bill Cassidy, R-La., on March 2 asked stakeholders to weigh in as they “intend bipartisan find solutions to improve the health of our country. staff shortages in healthcare and develop these ideas into legislation.”
HELP and House Energy and Commerce have jurisdiction over the National Health Service Corps, which expands the primary care workforce, including OB-GYNs, and the Teaching Health Centers Graduate Medical Education Program, which trains medical residents, including OB-GYNs. Both programs must be re-approved this year.
At a hearing on Feb. 16, Cassidy called for both to renew on time and pay in full, and Sanders said he wanted to expand the health center’s education program and increase student loan forgiveness and grants through the National Health Service Corps program.
Burgess also stressed the need to retain physicians already employed, reduce paperwork associated with prior authorization, and increase reimbursement rates.
But staffing programs aimed at recruiting midwives can also face political backlash.
The American College of Obstetricians and Gynecologists, which represents more than 60,000 members, faced backlash at its annual conference in February after the American Association of Pro-Life OB-GYNs said it was denied access to the meeting because of its opposition against abortion rights.
“This is a blatant attack on the exploration of research and practice that academia is supposed to promote,” said Robert B. Aderholt, R-Ala. Action team.
Five House Republicans also issued a joint statement that they “will push for immediate changes to this unacceptable behavior — whether that means holding ACOG accountable at meetings or refusing meetings until they change course.”
About half of maternal complications occur after the baby is born, according to the Commonwealth Fund, and doctors and experts alike say these problems could be alleviated with more postpartum health care visits, which screen for anything from breastfeeding complications to hypertension, diabetes or postpartum depression .
Federal law mandates Medicaid postpartum coverage for mothers and infants for 60 days after birth, but 29 states and the District of Columbia have expanded access to Medicaid for mothers and infants for 12 months postpartum, with more states in the process.
The 2021 COVID-19 relief bill gave states the option to expand Medicaid’s postpartum coverage. The option started in April 2022 and is available for five years. States that expanded Medicaid postpartum coverage before April 2022 did so through a Section 1115 exemption or through state funds.
New parents who have access to covered postpartum care are much more likely to look for it, even if it means traveling far out of the way or driving more than an hour there and back for an appointment, Cherot said.
According to a 2020 Kaiser Family Foundation survey, approximately 78% of midwifery practices accept Medicaid, and Medicaid pays for more than 4 in 10 births nationwide. Still, the program reimburses doctors at a much lower rate than commercial payers. In many states, Medicaid pays providers less than half of what it costs to give birth.
In turn, the lack of payment can lead hospitals to cut obstetric staff or close obstetric departments because they are not generating enough revenue.
“What is hurting physician recruitment and retention across the board right now is what is happening with reimbursement rates in Medicare and Medicaid. It’s just phenomenally damaging,” Burgess said.